In the event of an episode of unstable angina during the first month of therapy drug Perindopril in patients with stable ischemic heart disease, it is necessary to evaluate the relationship between the benefit and the risk of continuing therapy with this drug.
ACE inhibitors can cause a sharp decrease in blood pressure. Symptomatic arterial hypotension is observed rarely in patients without concomitant diseases. The risk of excessive decline AD is higher in patients with reduced BCC (taking diuretics, if you follow a diet with restriction of consumption of cookery salt, with hemodialysis, vomiting, diarrhea, and also in patients with severe degree arterial hypertension with high renin activity of blood plasma). This complication is most typical for patients with severe chronic heart failure as in presence of concomitant renal disease insufficiency, and in its absence (most often this side effect is noted in patients receiving "loop" diuretics in high doses, and also in patients with hyponatremia or with impaired renal function). Have patients at increased risk symptomatic arterial hypotension initiation of therapy should be careful medical supervision. Have patients with ischemic heart disease or with cerebrovascular diseases severe arterial hypotension may lead to the development of myocardial infarction or cerebrovascular complications. AT communication with this treatment of such patients also should start under the medical supervision with further careful titration dose depending on the clinical effect and tolerability. Before starting therapy with the drug Perindopril, as well as other inhibitors ACE, as well as during its administration should carefully monitor blood pressure, indicators of kidney function and the content of potassium ions in the blood serum.
In order to reduce the likelihood of symptomatic arterial hypotension in patients receiving diuretic therapy in high doses, they should be canceled 2-3 days before the drug is started Perindopril. In the future, if necessary, diuretic therapy can be resumed under the close supervision of blood pressure.
In the case of development of arterial hypotension, the patient should take a horizontal position, if necessary, he should undergo an intravenous infusion with the use of 0.9 % solution of sodium chloride. A marked decrease in blood pressure at the first intake of the drug Perindopril is not a contraindication for its further application. After the recovery of bcc and blood pressure, treatment can be continued provided that the dose of the drug is carefully selected.
In patients with symptomatic heart failure, arterial hypotension, which may develop in the initial period of therapy with ACE inhibitors, can lead to impaired renal function. In some cases, there has been a reported development of acute renal failure, which is usually is reversible. In patients with bilateral stenosis renal artery or stenosis of the artery the only kidney (especially if available renal failure) on the background of therapy ACE inhibitors may increase concentrations of urea and creatinine in blood serum. These changes are usually return to normal after cancellation preparation.
In some patients with arterial hypertension, if not previously available revealed renal failure, especially with concomitant use diuretic drugs may increase concentration of urea and creatinine in blood serum. These changes are usually are slightly expressed and carry reversible character. In this case it is recommended that the dose be reduced Perindopril and / or cancellation of the diuretic.
The use of ACE inhibitors in patients with Renovascular Hypertension is accompanied by an increased risk development of severe arterial hypotension and renal insufficiency. Treatment of such patients begin under careful medical supervision using preparation in small doses and further adequate choice of dose. During first few weeks of therapy it is necessary to temporarily stop treatment diuretics and monitor kidney function.
Anaphylactoid reactions can also develop with the use of inhibitors ACE in patients who underwent apheresis of low density lipoproteins absorption by dextran sulfate or in patients on hemodialysis with high-flow membranes, such as polyacryl nitrile. Therefore, similar combinations should be avoided by applying or other antihypertensive drugs, or alternative membranes for hemodialysis.
Data on the use of the drug Perindopril after kidney transplantation are absent.
In the treatment with ACE inhibitors, cases of angioedema, swelling of the face, lips, language, vocal folds and / or larynx, in number of patients who received Perindopril.This complication may occur at any stage of therapy. Edema tongue, vocal cords or larynx may lead to airway obstruction. ways. When a laryngeal whistle appears or angioedema, edema, tongue or vocal cords of the drug Perindopril should be immediately discontinued.
Emergency therapy includes, In addition to other appointments, immediate subcutaneous injection of epinephrine solution (adrenaline) 1: 1000 (1 mg / ml) 0.3-0.5 ml or slow intravenous administration (in according to the preparation of the infusion solution) under the control of ECG and blood pressure. The patient should be hospitalized for treatment and follow-up for at least 12-24 hours and until the symptoms regress completely.
In the treatment of ACE inhibitors, cases of angioedema of the intestine are also described. Patients noted abdominal pain (with / without nausea or vomiting); in some cases without a previous angioedema and a normal level of C-1 esterase. The diagnosis was established using computed tomography of the abdominal region, ultrasound examination or at the time of surgery.Symptoms disappeared after discontinuation of ACE inhibitors. Therefore, in patients with abdominal pain taking ACE inhibitors, when establishing a differential diagnosis, it is necessary to consider the possibility of developing angioedema of the intestine.
Patients who have a history of angioedema, not associated with an ACE inhibitor, may be at increased risk of developing it when treated with drugs of this group.
Patients receiving ACE inhibitors during desensitizing therapy with Hepaticoptera venom can develop anaphylactoid reactions, life-threatening. By temporarily stopping the use of ACE inhibitors, these reactions could be avoided, but they arose again with the occasional administration of these drugs.| Very rarely, with the administration of ACE inhibitors, cases of the development of the syndrome, which began with the development of cholestatic jaundice, progressed to fulminant liver necrosis and in some cases resulted in death. The mechanism of development of this syndrome is not clear. Application of the drug Perindopril in patients with signs of jaundice development or a significant increase in the activity of "hepatic" enzymes, it is necessary to cancel and conduct appropriate monitoring of laboratory parameters and the patient's condition. |
There have been cases of development of neutropenia / agranulocytosis, thrombocytopenia and anemia in patients receiving ACE inhibitors. Such cases are quite rare in patients with normal renal function. Neutropenia and agranulocytosis disappear after the withdrawal of ACE inhibitors. Perindopril should be used with extreme caution in patients with systemic vasculitis receiving immunosuppressive therapy, treatment with allopurinol or procainamide, or with combination these risk factors, especially in patients with impaired renal function. In these patients, in some cases, may develop infections that are resistant to antibiotics. In the case of drug use Perindopril these patients should be monitored regularly for blood leukocytes. If any symptoms of infection (eg, sore throat, fever) appear, the patient should consult a doctor immediately, as they may be a manifestation of neutropenia.
It should be borne in mind that in patients of the Negroid race the risk of angioedema development is higher. Like other ACE inhibitors, perindopril is less effective as an antihypertensive drug in patients of the Negroid race. This effect is probably associated with a marked predominance of low-grade status in patients of the Negroid race with arterial hypertension.
Cough that occurs with the use of inhibitors ACE, is unproductive, persistent and passes after discontinuation treatment. In the differential diagnosis of cough, its possible association with ACE inhibitors should be considered.
The use of ACE inhibitors in patients, whose condition requires surgical and / or, if necessary, general anesthesia, can lead to the development of arterial hypotension or collapse, which is due to a sharp increase in antihypertensive activity. Should warn surgeon / anesthesiologist about the use of ACE inhibitors and stop taking the drug Perindopril for 24 hours before surgery (including dentistry). With the development of arterial hypotension, it is necessary to maintain blood pressure by replenishing the BCC. With the use of ACE inhibitors, it is possible to develop hyperkalemia. Risk factors for hyperkalemia include renal failure, elderly age (over 70 years), diabetes mellitus, concomitant pathological conditions (in particular, a decrease in BCC, acute cardiac decompensation, metabolic acidosis). Giperculosis may cause severe, sometimes fatal cardiac rhythm disturbances. It is recommended to periodically monitor the content of potassium ions in the blood plasma.
It is usually not recommended to apply Perindopril and potassium preparations, salt substitutes containing potassium ions, potassium-sparing diuretics (spironolactone, triamterene or amiloride) diuretics (spironolactone, triamterene or amiloride) or other drugs associated with risk of increasing the potassium content (eg, heparin) because of the possibility of severe hyperkalemia. If joint intake of these drugs is necessary, then therapy should be accompanied by regular monitoring of potassium in the blood serum. Patients with diabetes may need more careful observation and correction of a dose of hypoglycemic agents for oral and insulin intake,especially during the first month of therapy with an ACE inhibitor, including Perindopril.
It is not recommended to apply simultaneously with the drug Perindopril lithium preparations.
Perindopril, like other ACE inhibitors, should be used with caution in patients with obstruction of the left ventricular outflow tract (aortic stenosis, hypertrophic obstructive cardiomyopathy), as well as in patients with mitral stenosis.